Hyperactive thyroid nodules treated by radiofrequency ablation: a Dutch single-centre experience

BACKGROUND

Hyperactive thyroid nodules (HTN) are usually treated with radioactive iodine (RAI). However, as RAI is associated with a 30-60% long-term risk of permanent hypothyroidism, radiofrequency ablation (RFA) may be a good alternative. Primary aim of this study was to assess the percentage of patients achieving euthyroidism after RFA.

PATIENTS AND METHODS

Patients with a symptomatic HTN were treated by ultrasound-guided RFA, using the trans-isthmic approach and moving-shot technique, in an outpatient setting under local anaesthesia.

RESULTS

Twenty-one patients were included, ranging in age from 37-75 years. Follow-up was at least one year. All patients had a suppressed serum thyroid-stimulating hormone (TSH), with free thyroxine (FT4) and free triiodothyronine (FT3) concentrations mildly elevated in 33% and 43% of cases, respectively. RFA was not associated with clinically meaningful adverse effects. TSH normalisation was achieved in 11/21 patients (52%) after first RFA. A partial response, defined as a normalisation of FT4 and FT3, but incomplete improvement of TSH, was observed in 6/21 patients (29%). Three patients had no response (14%), and one patient developed mild, asymptomatic subclinical hypothyroidism. Five patients underwent a second RFA and this led to TSH normalisation in four, thereby raising the rate of complete remission to 71%. Recurrence of TSH suppression did not occur during the study period.

CONCLUSION

These data suggest that RFA is a safe and promising treatment for symptomatic hyperactive thyroid nodules, with a low risk of permanent hypothyroidism. Long-term studies are needed to identify the recurrence risk of hyperthyroidism.

Magnetic resonance imaging in patients with meningitis induced hearing loss

The aim of this multicentre study was to compare T1 with T2 weighted MRI scans of the labyrinth after meningitis and to investigate whether waiting with scanning improved the reliability of diagnosing an ongoing process such as cochlear osteogenesis. Forty-five patients were included who suffered from meningitis induced hearing loss (radiological imaging <1 year after meningitis). Twenty-one gadolinium enhanced T1 and 45 T2 weighted MRI scans were scored by two radiologists regarding the condition of the labyrinth. These radiological observations were compared with the condition of the cochlea as described during cochlear implantation. A higher percentage of agreement with surgery was found for T2 (both radiologists 73%) than for T1 weighted MRI scans (radiologist 1: 62%, radiologist 2: 67%), but this difference is not significant. There was no significant difference between early (0–3 months) and late (>3 months) scanning, showing that radiological imaging soon after meningitis allows early diagnosis without suffering from a lower agreement with surgical findings.

A half-yearly chest radiograph for early detection of lung cancer following oral cancer

In a retrospective analysis of 339 patients, treated with a curative intention for a squamous cell carcinoma of the oral cavity between 1988-1996, the value of a half-yearly routine chest radiograph during the first 2 years of follow-up, was evaluated. Metastatic or primary lung malignancies developed in 18 (5.3%) of the 339 patients in the first 2 years of the follow-up. In 11 (3.2%) patients these malignancies were detected on routine chest radiographs while in 7 (2.0%) patients these were detected on chest radiographs taken because of pulmonary complaints. The mean survival after detection of the pulmonary malignancy was 8 months. All patients died within 21 months, independent of pathology or therapy. No correlation was found between stage, location or differentiation of the primary tumour. As a result of this study it can be concluded that there is no benefit for the patient for a 6-month thoracic radiograph in routine follow-up for patients with oral squamous cell carcinoma. It gives false certainty and burdens the health care system.

Botulinum toxin A: a new option for treatment of drooling in children with cerebral palsy. Presentation of a case series

Drooling beyond the age of 4 years is pathological, particularly if it occurs in children with neurological and developmental impairment and disability. Considering the therapeutic spectrum of botulinum toxin A and in view of the innervation of the salivary glands, we postulated that intraglandular injections into the submandibular glands with botulinum toxin A could reduce the secretion of saliva and consequently decrease drooling. Three patients with cerebral palsy and severe drooling were selected and evaluated over a 4-month period. Under ultrasound guidance, one dose of botulinum toxin A was injected bilaterally into the submandibular glands. Saliva secretion was measured at baseline and repeated four times during the following 4 months. In the three patients, maximal salivary flow rate of the sublingual and submandibular glands was reduced by 51% to 63%. The time of the maximal effect differed among the three children. The parents reported a satisfactory reduction of drooling throughout the whole study period. No objectionable disturbances of oral functions were observed. There was mild transient thickening of saliva in one of the patients.

CONCLUSION

The application of botulinum toxin A to the submandibular gland is a promising technique to reduce salivary flow rate and probably an alternative in the treatment of drooling in children with cerebral palsy.

Sagittal computerized tomography reconstruction of the lateral nasal wall for functional endoscopic sinus surgery

Coronal computerized tomography (CT) scanning is imperative in the preoperative work-up for functional endoscopic sinus surgery (FESS). This study describes additional information provided by lateral CT reconstruction with special attention to the (naso-) frontal recess. Thin axial scans were taken from 10 patients suffering from chronic rhinosinusitis. This procedure avoided artefacts from dental fillings on the computerized reconstructions. The common landmarks of the lateral nasal wall as described in the surgical anatomy of FESS were easily identified on sagittal views. The average angulation of the sagittal plane from the midline required to obtain optimal images of the frontal recess was antero-posteriorly 8.7 degrees (SD, 2.4), cranio-caudally 7.7 degrees (SD, 2.6). Size and condition of the frontal recess could be demonstrated. Variations of the angle between frontal sinus and ethmoid infundibulum appeared to depend on the anterior projection of the frontal sinus and may give an indication as to the optimal endoscopic angle for visualization of the frontal ostium. Sagittal reconstructions provide information for better spatial orientation particularly in the plane of the surgical approach and may help to diagnose underlying functional changes of chronic frontal sinusitis.

Autosomal dominant non-syndromal low-frequency sensorineural hearing impairment linked to chromosome 4p16 (DFNA14): statistical analysis of hearing threshold in relation to age and evaluation of vestibulo-ocular functions

A Dutch kindred was studied with low-frequency sensorineural hearing impairment linked to a new locus on chromosome 4p16 (DFNA14). Of the affected individuals, 21 (aged 11-75 years) were examined and the most recent audiogram was used for cross-sectional analysis of hearing threshold in relation to age. Suitable serial audiograms were available for a longitudinal analysis in nine cases: they had been obtained from the age of six years onwards and covered a follow-up period from 14 to 36 years. The presumably congenital (offset) component of SNHI was extrapolated or estimated from average values and offset thresholds were found of about 45 dB at 0.25-1 kHz, 25 dB at 2 kHz and 10 dB at 4-8 kHz. Significant progression in hearing impairment occurred at all frequencies, but could be attributed to presbyacusis. The combination of congenital, stationary low-frequency SNHI and presbyacusis resulted in an up-sloping audiogram in the first five decades of life, which evolved into a flat-type audiogram in the sixth or seventh decade and a down-sloping audiogram at a more advanced age. With few exceptions, vestibular function was intact.

Fibroinflammatory pseudotumor of the ear. A locally destructive benign lesion

We describe three cases of a fibroinflammatory pseudotumor (tumefactive fibroinflammatory lesion) of the middle and inner ear. The patients presented with total deafness in the affected ear and no response to caloric stimulation. The computed tomographic pattern showed destruction of inner ear structures and a typical widening of parts of the labyrinth. Magnetic resonance imaging performed in all three patients showed an extension greater than expected based on computed tomographic images of both areas of destruction, as well as areas of radiologic normality. An enhancing mass was seen in the inner ear with a characteristic extension into both the internal auditory canal and the middle ear. A transotic approach or subtotal petrosectomy was used to remove the tumor in all three cases. Although histologically benign, these tumors are locally destructive and, as such, behave like a neoplastic lesion. They are composed of fibrovascular tissue admixed with chronic inflammatory cells. To our knowledge, this is the first report on pseudotumors of the middle ear, inner ear, and internal auditory canal. Inflammatory pseudotumor used to be a somewhat confusing term for a recognized entity of unknown origin. It is likely that infection is an important contributing factor in the development of these lesions. Although surgical removal seems to be the treatment of choice, no clear judgment of its prognosis can be made owing to the rarity of this tumor.

Subcutaneous emphysema of the lower extremity secondary to a perforated esophageal carcinoma

The psoas muscle is a potential pathway of disease from the mediastinum to the leg. We describe a case of subcutaneous emphysema of the lower extremity due to a perforated esophageal carcinoma in a 58-year-old man.

Intratumoral PEG-interleukin-2 therapy in patients with locoregionally recurrent head and neck squamous-cell carcinoma

BACKGROUND

An enhanced efficacy of local as compared to systemic administration of interleukin-2 (IL-2) has been demonstrated in several experimental tumors. We previously reported that guinea pigs with palpable tumors and regional micrometastases could be cured by intratumoral injections of polyethylene glycol-modified IL-2 (PEG-IL-2). In the present study this treatment schedule was applied in a clinical situation.

PATIENTS AND METHODS

Nineteen patients with 11 local and 11 regional recurrences of head and neck squamous cell carcinoma (HNSCC) were treated with intratumoral injections of 200,000 U of PEG-IL-2 3 times weekly in courses of 4 weeks.

RESULTS

Treatment was given on an out-patient basis, and was well tolerated. Temporary regional swelling and redness developed in 10 patients, and in 9 of them systemic eosinophilia was documented. Median duration of treatment was 4 weeks (range 2-14 weeks). Seventeen patients were evaluable for response. One complete response (CR; 6%; duration 91 weeks), and 6 stable diseases (SDs; duration 8-57+ weeks) were recorded. The CR and the 3 best SDs (23, 40, 57+ weeks) occurred in patients with a single regional tumor recurrence of relatively small size. During treatment, all 4 developed locoregional edema and redness, and high levels of circulating eosinophils. Median survival was 23 weeks for all patients, and 45+ weeks for the patients with SD.

CONCLUSION

Intratumoral injection of PEG-IL-2 in patients with HNSCC is feasible. This treatment appears beneficial for highly selected patients. The objective response rate is insufficient to justify wide clinical application.

[Roentgenology of cancer of the gastric stump]

The carcinoma of the stomach stump is a late complication after partial resection of the stomach and gastroenterostomy. The risk for carcinoma increases with the interval, but in older people the interval is shorter. 12 patients with carcinoma of the stomach stump are discussed. The average interval from the primary operation of the stomach until the carcinoma was 23.8 years. With x-ray examination the diagnosis was correct in 11 patients, in 1 patient the examination was interpreted falsely.